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RESEARCH ARTICLE

Open Access

Exploring salivary cortisol and recurrent pain in
mid-adolescents living in two homes
Emma Fransson1*, Lisa Folkesson1,2, Malin Bergström1, Viveca Östberg1 and Petra Lindfors2

Abstract
Background: Each year, around 50.000 children in Sweden experience a separation between their parents. Joint
physical custody (JPC), where the child alternates homes between the parents for about equal amount of time, has
become a common living arrangement after parental separation. Children in two homes could benefit from
everyday contact with both parents and access to both parents’ financial resources. However, children could
experience stress from being constantly moving and potentially exposed to parental conflicts. Still, studies on JPC
and biological functioning related to stress, are lacking. The aim of this study was to investigate how living
arrangements (intact family/JPC) relate to HPA-axis activity and recurrent pain in mid-adolescents.
Methods: Mid-adolescents (106 girls and 51 boys) provided demographic details, self-reports of recurrent pain
(headache, stomachache, neck/shoulder and back pain) and salivary samples. Salivary cortisol samples were
collected: 1) immediately at awakening, 2) +30 minutes, 3) +60 minutes, and 4) at 8 p.m. The cortisol awakening
response (CAR) was computed using an established formula. Additionally, the diurnal decline between the waking
and 8 p.m. samples was computed.
Results: Hierarchical multiple regressions showed that living arrangements (intact family/JPC) was not associated
with morning cortisol (CAR), the diurnal cortisol decline or with recurrent pain. However, sex was a significant
predictor of both cortisol measures and recurrent pain with girls exhibiting a higher cortisol awakening response
and a greater diurnal decline value as well as reporting more recurrent pain than did boys.
Conclusions: Living arrangements were not associated with HPA-axis activity or recurrent pain in this group of
well-functioning mid-adolescents. Although this study is the first to investigate how living arrangements relate to
HPA-axis functioning and additional studies are needed, the tentative findings suggest that these mid-adolescents
have adapted to their living arrangements and that other factors play a more pertinent role for HPA-functioning

and subjective health.
Keywords: HPA-axis activity, Cortisol, Mid-adolescence, Recurrent pain, Joint physical custody

Background
Each year, around 50.000 children in Sweden experience a
separation between their parents and in 2008, 32 percent
of adolescents had divorced parents (Statistics Sweden
2009). Traditionally in Western societies, children have
tended to stay with their mothers after parental separation
(Kelly 2007; Skjørten et al. 2007). However, the practice of
joint physical custody (JPC), where the child alternates
homes between the parents for about equal amount of
time, is increasing in many Western countries, such as
* Correspondence:
1
Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska
institutet, 106 90 Stockholm, Sweden
Full list of author information is available at the end of the article

Australia, the U.S and several European countries (Bakker
and Mulder 2013; Kaspiew et al. 2011; Lavadera et al.
2013; Melli and Brown 2008; Sodermans et al. 2013). In
Sweden about one in ten of all mid-adolescents live in two
homes (Bergström et al. 2013), and this practice has been
reported as equally common as sole mother custody for
recently separated parents (Swedish Government Official
Report 2011).
Arguments favoring JPC concern the benefit of keeping close relationships and everyday contact with both
parents along with potential benefits of having access to
both parents’ financial and social resources (Breivik and

Olweus 2006; Skjørten et al. 2007). Concerns involve the

© 2014 Fransson et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License ( which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver ( applies to the data made available in this article,
unless otherwise stated.


Fransson et al. BMC Psychology 2014, 2:46
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potential stress of being constantly moving and perhaps
being more exposed to parental conflicts (Bauserman
2002). Additional stress exposures for adolescents in JPC
may involve feelings of alienation from living in two separate worlds and daily stressors including long distances to school, friends and leisure activities, instability
in parenting and a need to adjust to the demands of two
different family lives (Bauserman 2002; Gilmore 2006).
Moreover, in an interview study from Australia, children
and adolescents in JPC brought up the hassles of leaving
things behind in the other home (Cashmore et al. 2010).
Despite the increased practice of JPC, research is limited
and has primarily focused on adjustment (Bauserman
2002). Studies including health measures have focused on
subjective health reports with a recent study (Carlsund
et al. 2013) indicating that adolescents living in two homes
report more subjective health complaints than do those in
intact families. However, studies on JPC and biological
functioning are lacking.
Psychosocial stress, in terms of the perception of immediate or long-term challenges or demands, which may
be associated with JPC, influences the hypothalamicpituitary-adrenal (HPA) axis and its regulation of cortisol

(O’Connor et al. 2000). Cortisol is important for translating long-term stress into pathological conditions (e.g.,
Gunnar et al. 2009). Individuals exposed to stress have
been found to exhibit for example lower cortisol levels at
waking and smaller declines during the day (Fisher et al.
2011) or a greater area under the daytime cortisol curve
(Suglia et al. 2010). Specifically, alterations in the diurnal
cortisol profiles have been linked to various health problems in children and adolescents (Rotenberg et al. 2012).
However, less is known about mid-adolescents’ living
arrangements and diurnal cortisol profiles, which motivates exploring further these linkages. Besides influencing
physiological functioning, psychosocial stress has also
been associated with increasing levels of recurrent pain
(Alfvén et al. 2008). Additionally, increased cortisol at
awakening has been linked to greater ratings of pain
(Goodin et al. 2012). This motivates investigating further
the linkages between living arrangements and recurrent
pain.
Previous studies have shown differences between girls’
and boys’ reactions following separation. For instance,
research has shown that boys may be at increased risk
for poorer mental health after parents’ divorce (Malone
et al. 2004; Spruijt and Duindam 2005) while girls have
been found more negatively affected by losing a father
figure (Nielsen 2011) or from being in father custody
(Naevdal and Thuen 2004). As for cortisol, differences
between adolescent girls and boys have been reported
with findings being inconclusive: some studies have
shown that stress is associated with larger cortisol expressions in boys (Zijlmans et al. 2013) while other

Page 2 of 7


studies have found the same but in girls (de Veld et al.
2012).
In view of the limited research on biological correlates
of JPC in adolescents, this study set out to investigate
the associations between living arrangements (intact
family/JPC) and salivary cortisol in mid-adolescent boys
and girls. Drawing on previous research (Carlsund et al.
2013), this study also investigated the associations between living arrangements and subjective health in terms
of recurrent pain. Following previous findings, JPC
adolescents were hypothesized to report more recurrent
pain than their peers in intact families. Due to the regular change of homes and the risk of exposure to parental
conflict, we also hypothesized that adolescents in joint
physical custody would show different cortisol profiles
as compared to those in intact families.

Methods
Participants

Adolescents aged 14–16 years were recruited through two
compulsory schools in Stockholm, Sweden, to participate
in a study of students’ daily life, health and well-being in
the 8th and 9th school years. The total population
included 545 adolescents. Of these, 413 (246 girls and
167 boys) completed an initial questionnaire that was
mandatory for inclusion in the cortisol study. In total, 285
adolescents (166 girls and 119 boys) lived in intact families
and 75 (48 girls and 27 boys) in two homes. Relatively few
adolescents lived with one parent only and since their
contacts with the other parent varied, these adolescents
were excluded (n = 49). Also, data from adolescents

suffering from chronic illness relating to hormonal functioning or taking medication influencing HPA-axis functioning (e.g., asthma and hypothyroidism) were excluded
(n = 3). Additionally, adolescents (n = 15) taking their first
sample more than 5 minutes after waking were excluded
(Smyth et al. 2013). The present study included 157 adolescents who provided four saliva samples, had complete
data on all self-report measures and were living either in
intact families or in two homes, moving between their
parents (JPC). A comparison of self-rated health and recurrent pain shows no significant differences between the
analytic sample and those responding to the questionnaire
regarding self-rated health (analytic sample: M = 1.86,
SD = .69; others: M = 1.82, SD = .74), or recurrent pain
(analytic sample: M =1.96, SD = 2.18; others: M = 1.77,
SD = 2.14). Comparisons in self-rated health and recurrent pain between adolescents with different living arrangements who provided saliva samples and those who
did not showed no significant group differences.
Procedure

The research team first implemented the study at the
two schools by meeting with school staff and parental


Fransson et al. BMC Psychology 2014, 2:46
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representatives. A letter was sent to all of the parents including information about the research project and a form
for informed consent regarding participation in a questionnaire study and a biomarker study respectively. Informed
consent from a parent was obtained for 83% of the adolescents (parents of 39 adolescents were unavailable). All these
adolescents were invited to participate in a questionnaire
study. Immediately before completing the questionnaire in
the classroom, all adolescents received oral and written information about the study and ten adolescents actively declined participation. The remaining adolescents who were
present at school gave written informed consent for the
questionnaire. Adolescents returning completed questionnaires were invited to the cortisol study and gave their
written informed consent separately for this sub-study.

Students returning saliva samples received a voucher
(USD 15). About 2/3 of those invited provided at least one
saliva sample. This research was approved by the Regional
Ethics Committee in Stockholm (Ref. no: 2009/857-31/4).
Living arrangements and recurrent pain
Living arrangements

Regarding demographics, participants were asked to indicate whom they were living with. Those with divorced or
separated parents were asked to indicate with yes or no
whether they had an additional home and if so how much
time they spent in each home. Response alternatives included “half the time”/“less than half the time”/“almost
never”. For this study, participants living with both their
parents in one home were categorized as intact families.
Participants with two homes where they stayed half the
time or less than half the time were categorized as having
joint physical custody.
Recurrent pain

Exposure to stressors is a major risk factor for recurrent
pain and co-occurrence of pain, such as headache and abdominal, back and limb pain (see Alfvén et al. 2008). The
questionnaire included four items asking about recurrent
pain. The question reads as follows: “During the past six
months, how often have you had the following problems?”.
The items on pain covered headaches, stomachache, back
pain and neck/shoulder pain with the response alternatives
“every day”, “several times a week”, “once a week”, “sometime during the month” and “less often or never”. Ratings
of each item were categorized to show weekly pain/less
than weekly pain. A sum score was computed reflecting
the number of different pains the participants experienced
at least once a week. Thus high scores indicate higher occurrence and co-occurrence of pain (Alfvén et al. 2008).

Salivary cortisol

This study uses saliva samples collected within two weeks
after completing the initial questionnaire, at four points in

Page 3 of 7

time during an ordinary school day: 1) immediately at
waking up, 2) at 30 minutes post-awakening, 3) at 60 minutes post-awakening, and 4) at 8 p.m. Saliva samples were collected using the Salivette® (Sarstedt Inc.,
Rommelsdorf, Germany), a plastic tube with a suspended
insert containing a sterile neutral cotton wool swab. Adolescents were instructed to chew on the swab for two minutes before putting it back into the tube and sealing it, or
to spit saliva directly into the tube, if preferred. Adolescents were also instructed not to eat, smoke, drink coffee/
tea (or other beverages containing caffeine), or brush their
teeth 10 minutes before sampling saliva (Hanrahan et al.
2006). All samples were stored in plastic-bags in room
temperature before returned to the research team on the
next school day. Then saliva samples were transported
to the laboratory where they were stored in a freezer
(-20°C) until analyzed. Cortisol was determined using
competitive radioimmunoassay (Spectria Cortisol RIA,
Orion Diagnostica, Espoo, Finland; intra-assay precision <5%, 1.7–4.1% and inter-assay precision <10%, 4.3–
9.0%). Each sample was analyzed twice and in randomized
order with values expressed in nmol/L.
Diary data

Each participant was instructed to complete a diary and
return it along with the test tubes. Details on time and
date for saliva sampling and questions on medication
and chronic diseases were included in the diary.
Statistics


Independent group t-tests and ANOVAs were performed
to investigate group differences. The main effect of living
arrangement (joint physical custody/intact family) was
tested using hierarchical blockwise multiple regression
analysis. Main effects of demographic characteristics including sex (0 = girl; 1 = boy) and school year (0 = 8th
year; 1 = 9th year) were controlled for and entered in the
first step. Living arrangements were included in the second step. The third and final step included the interactions between sex∗living arrangements to allow for
examination of their effects on each outcome. Due to
non-normality, cortisol values were log transformed.
The established formula (Pruessner et al. 2003) was then
used to compute the cortisol awakening response, CAR
with respect to ground. The CAR included the sample
collected 1) at waking, 2) 30 min post awakening and 3)
60 min post awakening. Additionally, the diurnal decline
was computed using the 1) waking and 4) evening samples. Post hoc power analyses were computed using
G*Power 3.1 (Faul et al. 2007).

Results
Of the mid-adolescents investigated here, 132 (89 girls and
43 boys) were living in intact families and 25 (17 girls and 8


Fransson et al. BMC Psychology 2014, 2:46
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boys) in two homes. Descriptive statistics with means (SD)
for cortisol (log transformed values) at different time
points for the different groups were as follows; Girls in
intact families: at waking: 2.39 (SD = .70); +30 min.:
3.10 (SD = .53); +60 min.: 2.90 (SD = .65); evening: .38

(SD = .82); Girls in two homes: at waking; 2.32 (SD = .72);
+30 min.: 2.99 (SD = .44); +60 min.: 2.80 (SD = .47); evening: .50 (SD = 1.00); Boys in intact families: at waking: 1.88
(SD = .71); +30 min.: 2.77 (SD = .57); +60 min.: 2.74
(SD = .46); evening: .31 (SD = .81); Boys in two homes: at
waking: 2.24 (SD = .71); +30 min.: 2.79 (SD = .43); +60 min.:
2.74 (SD = .44); evening: .43 (SD = 1.53).
ANOVAs investigating differences between girls and
boys with different living arrangements showed no significant effects of living arrangement for any of the dependent
measures. Descriptive statistics for the dependent measures were as follows: The mean CAR for adolescents in
intact families was 167.75 (SD = 32.05) while it was 175.74
(SD = 33.03) for those in two homes. For the diurnal decline measure, the mean for adolescents in intact families
was 1.87 (SD = 1.10) while it was 1.83 (SD = 1.07) for those
in two homes. Figure 1 shows the diurnal variation in
cortisol for adolescents with different living arrangements.
As for recurrent pain the mean for adolescents in intact
families was 1.92 (SD = 2.12) and 1.68 (SD = 2.01) for
those in two homes.
Table 1 summarizes results of the hierarchical regressions for the cortisol measures. For cortisol during the
first hour of awakening (CAR), sex emerged as a significant predictor across both steps with girls exhibiting
a higher cortisol awakening response. Similarly, girls had
a greater diurnal decline value. School year, the other
predictor entered in the first step, was not significantly
associated with any of the cortisol measures. Living
arrangements were added in the second step but did not
emerge as a significant predictor and there was no increase in the proportion of explained variance. Adding
the sex∗living arrangement in the final step did not increase the amount of explained variance and the interaction term was not significantly associated with any of
the cortisol measures.
As regards recurrent pain (Table 2), sex emerged as a
significant predictor with girls reporting more recurrent
pain than did boys. School year, however, was a nonsignificant predictor across both steps. Similar to the

cortisol measures, living arrangements did not emerge as
a significant predictor and the proportion of explained
variance did not increase. Finally, adding the interaction
between sex and living arrangement did not increase the
amount of explained variance and there was no significant
association with recurrent pain.
Post hoc power calculations resulted in perceived
power as follows: CAR, .02; diurnal decline, .05; recurrent pain, .08.

Page 4 of 7

Figure 1 Means and standard error of means for log
transformed cortisol values (nmol/L) at four time points
(1 = waking, 2 = +30 min, 3 = +60 min and 4 = at 8 p.m)
among adolescents living in one (n = 132) and two homes
(n = 25) respectively.

Taken together, living arrangements did not predict
objective or subjective measures. Instead, sex was a significant predictor of the objective cortisol measures and
the subjective measure (recurrent pain).

Discussion
Investigating morning and diurnal HPA-axis activity and
recurrent pain, the present findings showed no significant effect of living arrangements on any of these
measures. The findings are at odds with the initial hypotheses. However, sex was, in line with previous research, associated with different cortisol profiles over the
morning hours and with the diurnal cortisol decline
(e.g., Folkesson et al. 2014; Kudielka et al. 2004), with
girls exhibiting a higher cortisol awakening response and
a greater diurnal decline value. Also, as could be expected, girls reported higher levels of recurrent pain
(King et al. 2011; Hjern et al 2008). Yet, to the best of

our knowledge, this study is the first study investigating
cortisol profiles in adolescents living in two homes, as
compared to adolescents in intact families.
Previous studies of linkages between JPC and physical
health measures in adolescents (self-reported health
complaints and psychosomatic symptoms) suggest a
somewhat higher incidence of poor health among JPC
adolescents as compared to those in intact families


Fransson et al. BMC Psychology 2014, 2:46
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Page 5 of 7

Table 1 Results of hierarchical regression analyses for cortisol measures, unstandardized and standardized regression
coefficients (N =157)
CAR
Predictor

Cortisol decline

Step 1
B

Step 2
Beta

Step 3

B


Beta

B

Step 1

Step 2

Step 3

Beta

B

Beta

B

Beta

B

Beta

Sex

-24.85***

-.36***


-24.83***

-.36***

-23.73***

-.35***

-.38*

-.17*

-.38*

-.17*

-45*

-.20*

School year

-5.91

-.09

-5.57

-.08


-5.30

-.08

-.07

.03

-.07

-.03

-.09

-.04

7.39

.08

-.06

-.02

Living arrangements
Sex∗living arrangements

9.64


.11

-6.95

-.05

-.20

-.07

.44

.09

R2 adjusted

.13***

.13

.13

.02

.01

.01

R2 change


.14***

.01

.00

.03

.00

.01

*p < .05, ***p < .001.
For CAR, CIs (95%) for the third step were as follows: sex (-34.80/-12.66), school year (-15.13/4.52), living arrangements (-6.23/-25.50), sex∗living
arrangements (-34.94/21.04).
For cortisol decline, CIs (95%) for the third step were as follows: sex (-85/-.06), school year (-.44/.26), living arrangements (-77/.37), sex∗living
arrangements (-.56/1.45).
Note: Sex: 0 = girls, 1 = boys; School year: grade 8 = 0; grade 9 = 1; Living arrangements: One home = 0, JPC = 1.

(Carlsund et al. 2013). However, in our sample, consisting
of Swedish middle class adolescents, living in two homes
might not be a sufficiently strong stressor to induce HPA
axis changes or increases in recurrent pain. Yet, recent research shows that children and adolescents in JPC fare better than those living solely with one parent (e.g. Bergström
et al. 2013; Bjarnason et al. 2012). In the present study,
mid-adolescents living with only one parent were excluded, due to small number of individuals and large variation in contact with the other parent in this group.
Compared with other countries, the group living solely
with one parent is decreasing. According to a recent Swedish study, 87 per cent of mid-adolescents in non-intact
families share their time between two homes even if all of
them do not spend equal amounts of time in both homes
(Bergström et al. 2013). However, the inconsistency between the present findings on recurrent pain and previous

Table 2 Results of hierarchical regression analyses for
recurrent pain, unstandardized and standardized
regression coefficients (N =157)
Recurrent pain
Predictor

Step 1

Step 2

Step 3

B

Beta

B

Beta

B

Beta

Sex

-1.23

-.27**


-1.23

-.27**

-1.22

-.27**

School year

.25

.06

.23

.06

.24

.06

-.23

-.04

-.22

-.04


-.02

-.01

Living arrangements
Sex∗living arrangements
R2 adjusted

.07

.06

.08

R2 change

.08

.01

.00

**p < .01.
For recurrent pain, CIs (95%) for the third step were as follows: sex (-1.97/-.47),
school year (-.43/.90), living arrangements (-1.30/.85), sex∗living
arrangements (-1.92/1.87).
Note: Sex: 0 = girls, 1 = boys; School year: grade 8 = 0; grade 9 = 1; Living
arrangements: One home = 0, JPC = 1.

research can perhaps be explained by the fact that the recurrent pain measure used here differs from the subjective

health complaint measure used by Carlsund et al. (2013).
Specifically, the recurrent pain measure analyzed here is
more specific than the measure used in the study by Carlsund and colleagues (2013) which also included mental
health complaints.
Other methodological considerations include the
cross-sectional design that limits conclusions regarding
causality and the lack of details on how long the adolescents have been living in JPC. Still, living arrangements
were not related to cortisol. Obviously, the sample size
was small which decreases power, hinders separate analyses of girls and boys and increases the risk for false
negative findings. Yet, the saliva sampling was monitored through adolescents taking notes of their sampling
times and behaviors. This allowed for detailed scrutiny
and exclusion of individuals not following sampling
instructions. Also, controlling for the time between
awakening and the first sample did not influence the
findings (results not shown). However, there were no
data on menstrual cycle phase or use of oral contraceptives available for the girls meaning that it was impossible to account for the influence of these factors on
the cortisol measures. Yet, the differences in cortisol
levels between girls and boys found here were in line
with previous findings on adolescents (Reynolds et al.
2013). Then again, the cortisol findings may also relate
to the fact that mid-adolescents generally are fairly
healthy with flexible physiology, which means that the
psychosocial stress of living arrangements is yet to be
translated into physiological changes influencing HPAaxis functioning and cortisol output.
While previous studies have included more heterogeneous samples, the present study included a homogeneous group living in socio-economically favorable


Fransson et al. BMC Psychology 2014, 2:46
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middle-class contexts. Also, this study was conducted in

a cultural setting where family policy strives towards
parental equality and where welfare policies aim to
reduce economical differences between single and cohabiting parents. Obviously, the present findings need
replication in larger studies with adequate power that
besides JPC adolescents and individuals in intact families
also include adolescents living with a single-parent only,
a group excluded here because of power reasons. Importantly, future studies on children and adolescents in
different family settings need to include measures of biological, psychological and health functioning to describe
properly any effects of various living arrangements.

Conclusions
The present findings showed that living arrangements
were not associated with HPA-axis activity or recurrent
pain. Although this study is one of the first to investigate
how living arrangements relate to HPA-axis functioning
and despite the need of additional research, the tentative
findings suggest that the mid-adolescents investigated
here have adapted to their living arrangements and that
other factors, beyond living arrangements, play a more
pertinent role for HPA-functioning and subjective health.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
EF conceived of the study and drafted the manuscript following discussions
with PL. LF collected the data and was together with PL responsible for the
screening of cortisol data. PL performed the statistical analyses and drafted
the methods section. PL and VÖ planned the overall project with PL
implementing the project and coordinating the data collection. MB assisted
in preparing the draft. All authors reviewed and approved the final
manuscript.

Acknowledgements
Thanks to all adolescents, parents, teachers and other school staff. In
addition to the research group including Dr. Sara Brolin Låftman, Associate
Professors Ylva B. Almqvist and Bitte Modin, thanks to Emeritus Professor Ulf
Lundberg for facilitating the use of the Hormone Laboratory at the
Stockholm University, Department of Psychology. Lisa Folkesson held a PhD
position at Centre for Health Equity Studies, Stockholm University/Karolinska
Institutet and Petra Lindfors held a senior research fellowship at the
Stockholm University, Department of Psychology and Stockholm Stress
Center. Financial support for the data collection and Viveca Östberg came from
the Swedish Council for Working Life and Social Research (Grant No. 2006-1637,
PI V. Östberg) while Emma Fransson and Malin Bergström were supported by
Länsförsäkringsbolagens forskningsfond.
Author details
1
Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska
institutet, 106 90 Stockholm, Sweden. 2Department of Psychology, Stockholm
University, Stockholm, Sweden.
Received: 3 February 2014 Accepted: 8 October 2014

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doi:10.1186/s40359-014-0046-z
Cite this article as: Fransson et al.: Exploring salivary cortisol and

recurrent pain in mid-adolescents living in two homes. BMC Psychology
2014 2:46.

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